The Bridging Effect of Artificial Dermis on Reconstruction of Skin Avulsion Injury.

Skin avulsion wounds are expected to be swollen and tense after trauma, and skin perfusion can be compromised after primary closure, resulting in wound dehiscence and poor healing. The artificial dermis (AD) serves as a dermal regeneration template that is used to heal skin defects with secondary intention. Therefore, the aim of this study is to evaluate the effect of AD application on traumatic skin avulsion injuries compared to conventional primary closure. A retrospective cohort of 20 patients with skin avulsion injuries were included the study: ten patients were treated with AD and ten patients were managed with primary closure. When compared to the primary closure group, AD group had a shorter average healing time (58.40 ± 26.94 days V 65.50 ± 46.45 days) and significantly higher flap viability (92.00 ± 13.17% V 78.00 ± 13.98%; p = .03). In conclusion, AD is a promising material for the treatment of skin avulsion injury and produces better clinical results.

Treatment algorithm for Kimura's disease: A systematic review and meta-analysis of treatment modalities and prognostic predictors.

BACKGROUND: Kimura's disease is a rare, chronic inflammatory condition that usually manifests as highly recurrent head and neck tumors. OBJECTIVE: Systematic review of recurrence predictors following surgical excision. MATERIALS AND METHODS: The pathologically confirmed cases at the tertiary medical center were reviewed. PubMed, Medline, the Cochrane Library, Web of Science, Airiti Library containing grey literature were searched through August 31st, 2019. RESULTS: A total of 31 articles were included for meta-analysis which revealed that surgical excision resulted in a lower recurrence rate (pooled odds ratio [POR] = 3.15, 95% confidence interval [CI] = 1.12-8.82; p = 0.03) than conservative measures. Surgery was an effective single treatment modality for patients with tumors smaller than 3 cm (POR = 2.89, 95% CI: 1.20-6.95; p = 0.02), symptom duration shorter than 5 years (POR = 3.11, 95% CI, 1.03-9.38; p = 0.04), peripheral blood eosinophilia less than 20% (POR = 4.49, 95% CI: 1.46-13.84; p = 0.009) or serum IgE level less than 10000 IU/ml (POR = 8.30, 95% CI: 1.05-65.34; p = 0.04). CONCLUSIONS: Directing patients with Kimura's disease through the treatment algorithm will reduce the recurrence rate. Combination adjuvant therapy with surgery is recommended for the following conditions -- a tumor greater than or equal to 3 cm in size, symptom duration longer than or equal to 5 years, peripheral blood eosinophilia greater than or equal to 20%, or serum IgE greater than or equal to 10000 IU/ml to achieve the optimal therapeutic outcome. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020173258 (http://www.crd.york.ac.uk/PROSPERO).

Supercritical Carbon Dioxide Decellularized Bone Matrix Seeded with Adipose-Derived Mesenchymal Stem Cells Accelerated Bone Regeneration.

Large bone fractures with segmental defects are a vital phase to accelerate bone integration. The present study examined the role of supercritical carbon dioxide (scCO2) decellularized bone matrix (scDBM) seeded with allogeneic adipose-derived mesenchymal stem cells (ADSC) as bio-scaffold for bone regeneration. Bio-scaffold produced by seeding ADSC to scDBM was evaluated by scanning electron microscopy (SEM). Rat segmental femoral defect model was used as a non-union model to investigate the callus formation in vivo. Histological analysis and osteotomy gap closure in the defect area were analyzed at 12 and 24 weeks post-surgery. Immunohistochemical expression of Ki-67, BMP-2 and osteocalcin was evaluated to assess the ability of new bone formation scDBM. ADSC was found to attach firmly to scDBM bioscaffold as evidenced from SEM images in a dose-dependent manner. Callus formation was observed using X-ray bone imaging in the group with scDBM seeded with 2 × 106 and 5 × 106 ASCs group at the same time-periods. H&E staining revealed ASCs accelerated bone formation. IHC staining depicted the expression of Ki-67, BMP-2, and osteocalcin was elevated in scDBM seeded with 5 × 106 ASCs group at 12 weeks after surgery, relative to other experimental groups. To conclude, scDBM is an excellent scaffold that enhanced the attachment and recruitment of mesenchymal stem cells. scDBM seeded with ASCs accelerated new bone formation.

Application of nanofat grafting to rescue a severe ischaemic hand with thromboangiitis obliterans: A case report about promising salvage procedure.

RATIONALE: Currently, there is no consensus regarding the best treatment for patients with thromboangiitis obliterans (TAO). Regenerative medicine, such as bone marrow stem cells or adipose-derived stem cell (ASC) transplantation, have proven efficacy in improving tissue perfusion and wound healing in clinical trials. In this case, we used nanofat grafting to treat severe conditions in a patient with TAO, with promising outcomes. PATIENT CONCERNS: This is a case of a 48-year-old smoker who presented with cyanosis in both hands and the right foot, with gangrenous changes. Investigative angiography showed severe vasospasm in the radial and ulnar arteries of the patient's left hand. Progressive cyanosis of the patient's left hand was noted which may eventually require amputation if left untreated. DIAGNOSES: He was diagnosed with TAO under the Shionoya diagnostic criteria. INTERVENTIONS: Fasciotomy and necrotic tissue debridement were performed, followed by centrifuged nanofat grafting. The nanofat graft was prepared using Pallua method and deployed with a MAFT-GUN (Dermato Plastica Beauty Co., Ltd., Kaohsiung, Taiwan). OUTCOMES: Three months later, computed tomography angiography revealed a radial artery patency. The patient's wrist function was preserved with uneventful wound healing. LESSONS: The regenerative ability of centrifuged nanofat grafts not only helps wound healing but also helps reverse vasospasm and preserve remnant tissue perfusion.

Low-Grade Myofibroblastic Sarcoma Arising From Keloid Scar on the Chest Wall After Thoracic Surgery.

Keloids are considered as benign fibroproliferative skin tumors, and rare cases of malignancies have been reported. We present a case of low-grade myofibroblastic sarcoma arising from a recurrent painful keloid scar on the right chest wall after video-assisted thoracic surgery for pneumothorax in a 77-year-old man. Wide composite excision of the keloid, surrounding ribs, and partial diaphragm were performed. The chest wall pleural defect was reconstructed with Teflon (Chemours, Wilmington, DE), and soft tissue was reconstructed with a transverse rectus abdominis myocutaneous flap. This case highlights that refractory keloids may be considered a harbinger of malignancy.

Supercritical Carbon Dioxide-decellularized Porcine Acellular Dermal Matrix combined with Autologous Adipose-derived Stem Cells: Its Role in Accelerated Diabetic Wound Healing.

Diabetes mellitus (DM) causes impaired wound healing by affecting one or more of the biological mechanisms of hemostasis, inflammation, proliferation, and remodeling and a large number of cell types, extracellular components, growth factors, and cytokines. Interventions targeted toward these mechanisms might accelerate the wound healing process. To evaluate the wound healing efficacy of supercritical carbon dioxide (scCO2)-decellularized porcine acellular dermal matrix (ADM) combined with autologous adipose-derived stem cells (ASCs) in streptozotocin (STZ)-induced DM rats. DM was induced by injecting rats with STZ; dorsal full-thickness skin (5 × 5 cm2) was created and treated with and without ASCs-scCO2-treated ADM to evaluate the wound healing rate through histological examination, fluorescence microscopic observation, and immunohistochemical analysis. In the present study, complete decellularization of the porcine dermal matrix was achieved through scCO2. Isolation of ASCs was conducted and evaluated using CD29+/CD31-/CD45-/CD90+ markers in flow cytometry, which indicated that more than 90% of cells were ASCs. The percentage of cells labeled with CD29+ and CD90+ was found to be 97.50% and 99.69%, respectively. The wound healing rate increased in all groups relative to the group with the DM wound without treatment. DM wound treated with ADM-ASCs showed significantly higher (p < 0.01) wound healing rate than DM wound without treatment. ADM-ASC-treated rats showed significantly increased epidermal growth factor, Ki67, and prolyl 4-hydroxylase and significantly decreased CD45 compared with the group with the DM wound without treatment. The intervention comprising ADM decellularized from porcine skin by using scCO2 and ASCs was proven to improve diabetic wound healing. ADM-ASCs had a positive effect on epidermal regeneration, anti-inflammation, collagen production and processing, and cell proliferation; thus, it accelerated wound healing.

Fat Grafting for Facial Contouring (Nose and Chin).

The concept of microautologous fat transplantation (MAFT), proposed by Lin and colleagues in 2007, emphasized that the volume of each delivered parcel should be less than 0.01 mL to avoid potential fat grafting morbidities. The MAFT-GUN facilitates control of the parcel volume and therefore substantially avoids central necrosis and associated complications. In this article, the authors present a simple, reliable, and consistent procedure based on MAFT for profiloplasty. Favorable outcomes with sustainable long-term effectiveness were obtained, further confirming that the MAFT technique is an alternative for facial contouring in the nose and chin.

Use of Extended Pedicled Transverse Rectus Abdominis Myocutaneous Flap for Extensive Chest Wall Defect Reconstruction After Mastectomy for Locally Advanced Breast Cancer.

BACKGROUND: The reconstruction of a large postmastectomy chest wall defect for patients with stage III/IV breast cancer is a challenge for plastic surgeons. In this study, we present the application of an extended transverse rectus abdominis myocutaneous (TRAM) flap to easily and safely reconstruct these defects. PATIENTS AND METHODS: A retrospective review from November 1997 to November 2016 revealed that 65 patients with stage III/IV breast cancer immediately underwent postmastectomy TRAM flap reconstruction. In total, 16 patients were enrolled in this study based on the inclusion criteria of a postmastectomy chest skin defect size of greater than or equal to 100 cm and a TRAM flap size of greater than or equal to 80% of the lower abdominal area for reconstruction. RESULTS: Eleven (68.9%) and 5 patients (31.3%) were diagnosed with stage III and stage IV breast cancer, respectively. The chest wall skin defects ranged from 135 to 440 cm. All flap areas exceeded 80% of the lower abdominal area. Overall, 100% of the harvested flaps were used in 3 patients, and only 1 patient had marginal necrosis in zone IV. No total flap loss was observed. The average length of hospital stay was 5.8 days, and the mean follow-up duration was 46.6 months (range, 4.5-117.7 months). On a Likert scale, the mean follow-up satisfaction score of 10 patients was 4.7. CONCLUSIONS: Even when the flap area exceeded 80% of the lower abdominal area, the extended TRAM flap proved an effective and viable method for the immediate reconstruction of extensive postmastectomy chest wall skin defects, resulting in few minor complications and high follow-up satisfaction scores.

Triamcinolone Acetonide Suppresses Keloid Formation Through Enhancing Apoptosis in a Nude Mouse Model.

BACKGROUND: Current understanding of steroid treatments for keloids is in regards to modulation of inflammation, proliferation, and apoptosis, with no in vivo study on the latter. Using a nude mouse model, we investigated whether triamcinolone acetonide (TA) injections induce keloids regression through enhancing apoptosis. MATERIALS AND METHODS: Thirty-six keloid specimens (1 × 1 cm) were harvested from 6 patients and separated into sets of 2 from the same patient: no treatment and intralesional TA injection (0.4 mg/mL/kg) at 8 weeks of postimplantation. One set was implanted in each of 18 randomly selected nude mice, which were separated into 3 groups based on time of keloid harvesting after treatment: group A, 2 weeks; group B, 8 weeks; and group C, 14 weeks. Each group had 1 set of specimen from each patient. Histological staining was performed with hematoxylin and eosin stain. Immunohistochemistry staining was performed for human-prolyl 4-hydroxylase (hPH4) and caspase 3 protein, along with terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. RESULTS: All keloid specimens survived, with no noted overgrowth. Hematoxylin and eosin staining revealed dense extracellular matrix and viable fibroblasts, and hPH4 immunohistochemistry revealed strong expression, demonstrating keloid viability. Caspase 3 protein and TUNEL expressions were significantly increased in the treatment versus control groups, demonstrating that TA injections induced apoptosis. CONCLUSIONS: Triamcinolone acetonide intralesional injections significantly increased apoptosis in keloids, represented by increased caspase 3 protein and TUNEL expressions, supporting that steroids suppress keloids in part owing to enhancement of apoptosis.

Hyaluronic Acid-Povidone-Iodine Compound Facilitates Diabetic Wound Healing in a Streptozotocin-Induced Diabetes Rodent Model.

BACKGROUND: This study investigated whether a hyaluronic acid-povidone-iodine compound can enhance diabetic wound healing. METHODS: A dorsal skin defect (6 × 5 cm) in a streptozotocin-induced diabetes rodent model was used. Seventy male Wistar rats were divided into seven groups: I, normal control; II, diabetic control, no treatment; III, diabetic rats, lower molecular weight (100 kDa) hyaluronic acid; IV, rats, higher molecular weight (1000 kDa) hyaluronic acid; V, rats, 0.1% povidone-iodine; VI, rats, lower molecular weight hyaluronic acid plus povidone-iodine; and VII, rats, higher molecular weight hyaluronic acid plus povidone-iodine. Histologic examination was performed with hematoxylin and eosin staining. CD45, Ki-67, prolyl 4-hydroxylase, and vascular endothelial growth factor were evaluated with immunohistochemical staining. RESULTS: Compared with the control, higher molecular weight hyaluronic acid plus povidone-iodine-treated rats had significantly reduced wound area (p < 0.001). Higher molecular weight hyaluronic acid plus povidone-iodine increased wound healing time when compared with higher molecular weight hyaluronic acid, povidone-iodine, or lower molecular weight hyaluronic acid plus povidone-iodine. Histology revealed significantly increased neovessels and suppressed inflammatory response in the higher molecular weight hyaluronic acid plus povidone-iodine group when compared with the control group. Immunohistochemical staining revealed significantly increased Ki67, prolyl 4-hydroxylase, and vascular endothelial growth factor expression, and suppressed CD45 expression in the higher molecular weight hyaluronic acid plus povidone-iodine group when compared with the other groups. CONCLUSION: Higher molecular weight hyaluronic acid plus povidone-iodine complex dressing significantly facilitated diabetic wound healing via increasing neovascularization and tissue regeneration and suppressing a proinflammatory response.

Three Simple Steps for Refining Transcutaneous Lower Blepharoplasty for Aging Eyelids: The Indispensability of Micro-Autologous Fat Transplantation.

BACKGROUND: Lower blepharoplasty has been used for rejuvenating lower eyelids, and diverse modifications have been used to treat conjunct deformities at the tear trough/lid-cheek junction. Strategies for recontouring prominent tear trough/lid-cheek junctions, including orbital fat manipulation, have been reported with good results in the literature. Micro-autologous fat transplantation (MAFT) is a previously unevaluated, potentially advantageous approach to blending the prominent tear trough/lid-cheek junction. OBJECTIVES: We determined the long-term results after 3-step transcutaneous lower blepharoplasty with MAFT for patients with aging eyelids and prominent tear trough/lid-cheek junctions. METHODS: We evaluated 205 patients with aging lower eyelids who underwent transcutaneous lower blepharoplasty with MAFT between October 2010 and September 2016. The 3-step procedure involved a subciliary elliptical skin excision, resection of 3 orbital fat compartments, and MAFT for the tear trough/lid-cheek junction employing a MAFT-GUN under intravenous anesthesia. RESULTS: The mean patient age was 52 years (range, 34-78 years). The mean operating time was 61 minutes. The mean fat volumes delivered to the tear trough/lid-cheek junctions were 2.80 mL and 2.76 mL for the left and right sides, respectively. The average weights of the 3 resected orbital fat compartments were 0.58 g for the left side and 0.56 g for the right side. Patients showed significant improvement and maintenance at an average follow-up of 60.2 months (range, 18-90 months). CONCLUSIONS: Three-step transcutaneous lower blepharoplasty with MAFT is an effective, reliable, and promising method with high patient satisfaction and minimal risk of complications. Long-term results demonstrated its utility for aging lower eyelid treatment.

Micro-Autologous Fat Transplantation for Treating a Gummy Smile.

BACKGROUND: A gummy smile is treated using many techniques, including botulinum toxin injection and various surgical interventions. Micro-autologous fat transplantation (MAFT) is a potentially advantageous alternative approach that has not been previously evaluated. OBJECTIVES: This study sought to determine the long-term results of MAFT in patients with a gummy smile. METHODS: Seven patients with gummy smiles were evaluated for MAFT treatment between October 2015 and April 2017. Centrifuged purified fat was micro-transplanted into the nasolabial groove, ergotrid, and upper lip areas using the MAFT-GUN while the patients were under total intravenous anesthesia. RESULTS: The mean age of the 7 patients was 31 years (range, 23-40 years). The mean operating time for MAFT was 52 minutes (range, 40-72 minutes), and the mean volume of fat delivered to the nasolabial groove, ergotrid, and upper lip was 16.1 mL. The mean decreases of gingival display in the right canine incisor, left canine incisor, right canine, and left canine teeth were 4.9, 4.6, 3.8, and 4.4 mm, respectively. The smiles of the 7 patients showed significant improvement at an average follow-up time of 12.9 months. CONCLUSIONS: Gummy smile treatment using MAFT is an effective, reliable, and relatively simple method, with high patient satisfaction and minimal risk of complications.

Combined Use of Liposuction and Arthroscopic Shaving for Delayed Debulking of Free Flaps in Head and Neck Reconstruction.

BACKGROUND: Bulky appearance after free flap reconstruction in patients with head and neck cancer is common and requires revision to achieve improved final outcomes. Although different delayed debulking methods have been reported, the procedure can be technically difficult in patients with severe scaring after adjuvant radiotherapy. The present study proposes a combined method of liposuction and arthroscopic shaving for delayed contouring of free flaps in head and neck reconstruction. METHODS: In this study, 12 patients with head and neck cancer who had bulky flaps after cancer ablation surgery and immediate free anterolateral thigh flap reconstruction were included. These patients underwent delayed debulking through the combined arthroscopic shaving and liposuction method at least 3 months after the initial reconstruction or the completion of adjuvant radiotherapy (if required). Age, sex, cancer stages, the presence or absence of adjuvant radiotherapy, the interval between the initial free flap reconstruction and the debulking procedure, complications, and subjective satisfaction ratings were recorded 1 and 6 months after the revision surgery. RESULTS: All patients were men, with an average age of 56.3 years (43-69 years), and 9 (75%) patients underwent adjuvant radiotherapy. Partial flap loss was not observed in the study patients, and subjective satisfaction ratings improved after the debulking procedure. CONCLUSIONS: The combined liposuction and arthroscopic shaving method can facilitate the debulking and contouring procedures in patients with head and neck cancer after free flap reconstruction. With appropriate timing, the combined procedure can be simple and safe, even in patients with severe scaring after adjuvant radiotherapy.

Management of venous ulcers according to their anatomical relationship with varicose veins.

Background Adequately excising varicose and incompetent perforating veins is necessary for reducing their recurrence rate of venous ulcer. Method In total, 66 venous ulcers (C6) in 1083 legs with primary varicose veins were managed through endoscopic-assisted surgery. In an endoscopic operative view, the nonvaricose, varicose, and incompetent perforating veins were clearly visualized and precisely dissected. The varicose and incompetent perforating veins were divided and completely excised. Result The varicose veins were traced to the base or periphery of the 55 ulcers. Moreover, 89.4% of the ulcers healed within 14 weeks. Kaplan-Meier analysis revealed a five-year recurrence rate of 0.0%, and the satisfaction mean score was 4.6. Conclusion Endoscopic-assisted surgery can be used to radically excise varicose veins complicated with venous ulcers; the surgery yields low recurrence and high satisfaction rates.

Simultaneous double free radial forearm flaps combined with coronoidectomy and myotomy to release bilateral severe trismus: A case report.

Oral cancers associated with submucosal fibrosis-induced trismus are common. They may affect the patients' quality of life, cause nutritional deficits, and interfere with postoperative cancer surveillance. In such cases, locating desirable recipient vessels in the head and neck can be difficult. This report presents a 47-year-old man with severe trismus caused by recurrent head and neck cancer, who had received multiple free-flap reconstructions after cancer ablation. Reconstruction was successfully achieved for the bilateral defects and releasing the trismus by using simultaneous double free radial forearm flaps as a chained flow-through pattern with one residual recipient vessel combined with the bilateral myotomy of the medial pterygoid and masseter muscles, and coronoidectomy. Both flaps survived without any postoperative complication. The maximal mouth opening measured by interincisal distance was 38 mm intraoperative and 32 mm during the 3-year follow-up period. This approach may be an effective option for releasing trismus when recipient vessels are lacking.

Long-Term Outcome of Microautologous Fat Transplantation to Correct Temporal Depression.

OBJECTIVE: Sunken temporal fossa appears oftentimes in Asians and resembles bad fortune that people wish to change. Numerous techniques and materials have been applied clinically for augmenting the sunken temporal fossa with variable results. The microautologous fat transplantation (MAFT) technique proposed by Lin et al in 2006 has demonstrated favorable results in facial rejuvenation. In the present study, the authors applied the MAFT technique with an innovative instrument in sunken temporal fossa and reported its results. METHODS: Microautologous fat transplantation was performed on 208 patients during the 4-year period starting in January 2010. Fat was harvested by liposuction, processed and refined by centrifugation at 1200 g for 3 minutes. Then purified fat was microtransplanted to the temporal fossa with the assistance of an instrument, MAFT-Gun. The patients were followed up regularly and photographs were taken for comparison. RESULTS: On average, the MAFT procedure took 48 minutes to complete. The average delivered fat was 6.8 ±â€Š0.2 mL/6.5 ±â€Š0.3 mL for the right/left side. The average follow-up period was 18 months. No complication including skin necrosis, vascular compromise, nodulation, fibrosis, and asymmetry was noted. The patient-rated satisfaction 5-point Likert scale demonstrated that 81.3% of all patients had favorable results (38.5% very satisfied and 42.8% satisfied). CONCLUSIONS: The concept and technique of MAFT along with the micro- and precise controlling instrument enabled surgeons to perform fat grafting accurately and consistently. In comparison with other strategies for volume restoration, the MAFT procedure demonstrated the patients' high satisfaction with the long-term results. Therefore, the potential of MAFT as an alternative strategy in sunken temporal fossa in Asians was emphasized.

Medial Orbital Wall Reconstruction With Porous Polyethylene by Using a Transconjunctival Approach With a Caruncular Extension.

BACKGROUND: The reported rate of isolated medial orbital wall fractures varies widely but has been found to be as high as 55% of all orbital fractures. Identifying and repairing medial orbital wall defects by using appropriate materials improves patient outcome considerably; however, most related research has focused on orbital floor defect management rather than medial orbital wall treatment, and no consensus on repairing medial orbital wall fractures exists. Furthermore, medial orbital wall fracture is a main cause of posttraumatic enophthalmos. In this study, we introduce a modified surgical technique for repairing large medial wall fractures stably, also reviewed relevant literature and established an algorithm for managing medial orbital wall fractures. METHODS: We reviewed the outcomes of facial trauma patients who underwent facial bone reduction and internal fixation surgery in our hospital between October 1, 2010, and October 1, 2013. The patients were all treated medial orbital wall reconstruction with porous polyethylene by using a transconjunctival approach with a caruncular extension for large medial orbital wall fractures. Medical records and radiologic images of the patients were reviewed retrospectively. The outcomes evaluated were trauma mechanism, clinical findings of ocular injury, preoperative and postoperative ocular symptoms, degree of enophthalmos, and orbital volume restoration after surgery. RESULTS: Transconjunctival approach with a caruncular extension was performed without any complications. The incidence of diplopia was 47.4% and enophthalmos (>2 mm) was 31.6%, with no significant diplopia and enophthalmos after surgery. Patients were symptom-free on follow-up. The average enophthalmos was successfully corrected from 0.88 mm preoperatively to 0.26 mm and orbital volume was corrected from 26.22 to 22.99 cm after surgery; these results also showed P less than 0.001. CONCLUSIONS: The current results suggest that the proposed method of medial orbital wall reconstruction, in which porous polyethylene is implanted by using a transconjunctival approach with a caruncular extension, yields favorable outcomes. The approach facilitates a wide visualization of the operative field, which provides sufficient working space for implant insertion and is consequently free from iatrogenic trauma or surgery-related complications.

Fat grafting for resurfacing an exposed implant in lower extremity: A case report.

RATIONALE: Although numerous reconstruction protocols have been reported for lower leg trauma, those for distal leg trauma remain few. We present the case of a woman with an implant exposure wound, who was successfully treated through fat grafting, without major flap surgery. PATIENT CONCERNS: An 83-year-old woman with an exposed implant in lower extremity received reconstruction surgery once and the surgery failed. She refused additional major surgery and negative pressure wound therapy. DIAGNOSES: The diagnosis of a tibia and fibula shaft open fracture (type IIIA) complicated with an exposed implant was made. INTERVENTIONS: The procedure was performed by deploying purified and emulsified fat with a Micro-Autologous Fat Transplantation gun. The required lipoaspirate amount was grossly estimated using a standard formula: 0.5 cc of a lipoaspirate per square centimeter of wound. We prepared the lipoaspirate simply through centrifugation followed by physical emulsification. The endpoint of fat grafting was when lipoaspirate began to flow out of the wound. The initial dressing after the procedure included the topical usage of biomycin ointment with AQUACEL Foam (ConvaTec Inc., NC, USA) coverage, which was later changed to INTRASITE gel (Smith & Nephew, London, UK) with a gauze dressing for 4 weeks. After 4 weeks, dressing components were changed to Mepilex (Mölnlycke Health Care, Gothenburg, Sweden) alone. OUTCOMES: The wound healed completely without requiring major flap surgery by 18 weeks after surgery. LESSONS: Fat grafting is one kind of cell therapy and potentially has regenerative effects during wound healing. Fat grafting is critical in the healing processes of complicated wounds and might be considered a step in reconstruction surgery.

Adipose-Derived Stem Cell Modulation of T-Cell Regulation Correlates with Heme Oxgenase-1 Pathway Changes.

BACKGROUND: The authors' previous proteome study revealed that haptoglobin was involved in adipose-derived stem cell modulation of allotransplant survival and T-cell regulation to induce immune tolerance. This study investigated whether adipose-derived stem cells could modulate T-cell regulation through haptoglobin and the downstream heme oxgenase-1 pathway in vitro. METHODS: Splenocytes were isolated from Lewis rat spleens and then CD3 T cells were purified using anti-CD3 beads. Adipose-derived stem cells were harvested from Lewis rats and co-cultured with the T cells. After Transwell co-culture at different periods, the authors analyzed cell proliferation with a bromodeoxyuridine assay. Cell extractions and culture supernatants were collected for further analysis. Heme oxgenase-1 and related protein expression levels from the adipose-derived stem cells and T cells were detected using Western blotting. The related cytokine expression levels were analyzed with enzyme-linked immunosorbent assay kits. Flow cytometry was used to detect the regulatory T-cell proportion. RESULTS: The adipose-derived stem cells significantly suppressed T-cell proliferation. The regulatory T-cell percentages were significantly increased in the adipose-derived stem cells that were co-cultured with T cells compared with T cells alone without adipose-derived stem cell co-culture. Heme oxgenase-1 expression in concanavalin A-stimulated T cells that were co-cultured with adipose-derived stem cells revealed a significant increase compared with concanavalin A-stimulated T cells alone. Cytokine assays of the culture supernatants revealed that transforming growth factor-ß and interleukin-10 were significantly increased and interferon-γ was statistically decreased in the adipose-derived stem cell-co-cultured T-cell group compared with other groups; however, blockade with a heme oxgenase-1 inhibitor (zinc protoporphyrin IX) protected against these changes. CONCLUSION: Adipose-derived stem cells modulate T-cell proliferation and enhance regulatory T-cell expression, and this correlated with heme oxgenase-1 expression and related cytokine pathway changes.